Fully Fit Questionnaire

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Cell Phone* This field is required.
Area Code
Phone Number
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Date of Birth* This field is required.
Date
Year
Month
Day
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Emergency Contact* This field is required.I don't put this on here because I think you are going to get hurt during this process. I do it because there might come a point where you just don't feel like checking in with me and you don't respond to my texts or emails. I get it, you might be frustrated or tired, or you might have some legitimate excuse that you aren't able to respond (death or sickness in the family). So this is on here so that if or when you do go a couple days without any contact I have someone that I can contact that will be able to get in touch with you. This can be a spouse, a co-worker, a roommate, a friend, or family member but it needs to be someone that when I call they are going to come find you and smack you upside the head, not literally although that would be funny, and get you back on track, or will be able to tell me that the reason you haven't checked in is a a legitimate one.
First Name
Last Name
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Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
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What goals do you hope to accomplish?* This field is required.
Fat Loss
Increased Strength
Increased Muscle Mass
Weight Gain
Better Digestion
More Energy
Better Sleep
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Out of all of these goals, which is the most important to you?* This field is required.
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Think about that last one for a second... what goal would you like to achieve related to that one area in the first 30 days in our group?* This field is required.
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What do you see being the biggest challenges for you to accomplish your goal?* This field is required.
Consistent Exercise
Diet
Time Management
Meal Planning
Checking in with us
Support from family, friend, coworkers
Staying focused on weekends
Nothing, I'm ready to go
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Is there anything else you would like to tell us about your health and fitness goal(s)?
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Do you have any diagnosed health problems, list condition(s). (Diabetes, heart disease, high blood pressure, hypothyroidism, etc)* This field is required.
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Do you have any physical limitations? (asthma, bad knees, back, wrists, etc)* This field is required.
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List any medications you are currently taking.
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Any additional health information you would like to share? (Hereditary diseases, hunches on potential issues, food allergies)
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What do you do for a living/occupation?* This field is required.
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How would you best describe your activity level during the day?* This field is required.
None, sedentary job, little activity at home
Moderate, light activity during the day and at home
Active, on your feet most of the day but nothing strenous
Heavy, on your feet and doing strenuous activity throughout the day
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Does your work involve shift work?* This field is required.
Yes
No
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Describe your work schedule, hours worked, time of day, days per week.* This field is required.
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Do you travel for work, if so how much?* This field is required.
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Tell us a bit about your family, if you have one, and weekly activities that you do with them? * This field is required.
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When do you typically go to bed?* This field is required.
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10
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Hour
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10
20
30
40
50
Minutes
AM
AM
PM
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When do you typically wake up?* This field is required.
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2
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Hour
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10
20
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Minutes
AM
AM
PM
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Describe your wake up routine. Do you need an alarm clock? Do you pop out of bed right away? Basically is waking up hard and how rested do you feel?* This field is required.
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Who does the grocery shopping in your house? Who does the cooking? Do you have any meal prep routines?* This field is required.
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Do you take any nutritional supplements? If so, what supplements and what dosage?* This field is required.
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How many times a week do you eat out at restaurants?* This field is required.
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Do you follow any dietary guidelines? Vegan, Paleo, Pescatarian, etc? Also explain if you have any known food intolerances or foods you avoid. * This field is required.
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On a scale of 1-10 how happy are you right now with your life?* This field is required.1 being not at all, 10 being I think I'm in heaven
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What makes you happy?* This field is required.
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On a scale of 1-10 how motivated are you with the work that you do?1 being I would rather pull my finger nails out, 10 being I can't believe you are wasting my time with this questionnaire I want to get back to work)
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On a scale of 1-10 how motivated are you in your personal life?* This field is required.1 being I think solitary confinement in a maximum security prison would be more enjoyable, 10 being I live with frickin' unicorns, this is amazing
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What motivates you?* This field is required.
Incentive - Getting rewarded for a job well done either with a physical item, money or gift. Example: You work extra hard to meet a business goal because it means you will receive a monetary bonus.
Fear - Avoiding negative consequences. Ex: You workout because you don't want to develop heart disease
Achievement - The satisfaction of knowing you can complete a new skill successfully. Also being recognized for a job well done. Example: Being recognized at a company party for leading the company in sales.
Growth - A desire to constantly change, to improve. The more you know the better, a continual learner. Example: Getting a special certification so that you can better serve your clients.
Power - This motivation comes from a desire of autonomy and having more control of your life and situation. It can also be connected to being able to control those around either positively or negatively. Example: You are motivated to learn the tax code so that you can prepare your own taxes and not rely on an accountant. Job title and authority would be another example.
Social - This type of motivation is because you want to feel accepted by peers or fit into a group. If you have a desire to serve others and contribute to society it is often due to social motivation. Example: You want become a better golfer because your closest friends are good golfers and you want to feel more welcome in their golf group.
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Are you married or in a relationship with someone?
Yes
No
Type option 3
Type option 4
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Are they supportive of your desire to get healthy??
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Thank you for taking the time to fill out this form and let us know more about you. If there is anything else you would like to let us know about concerning your diet, health, fitness, family, routines, work or whatever please do so below.
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